A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is A
Explanation
A. An antipsychotic agent, particularly first-generation antipsychotics, can cause extrapyramidal symptoms such as tremors, drooling, gait changes, and spasms due to their dopamine-blocking effects in the brain.
B. An antidiabetic agent does not typically cause these neurological symptoms; its primary effects are related to glucose metabolism.
C. A general anesthetic is used to induce unconsciousness and does not generally result in muscular tremors or drooling.
D. An anticholinergic agent can cause side effects like dry mouth and constipation but does not typically lead to the muscular symptoms described; in fact, it may reduce drooling.
Correct Answer is B
Explanation
A. While dietary intake is important, especially regarding sodium and fluid balance, it is not the highest priority compared to monitoring blood pressure.
B. Monitoring the client's blood pressure is essential to evaluate the effectiveness of the prescribed antihypertensive medications and to ensure the client is within the target range for managing her hypertension.
C. Weighing the client is important for monitoring fluid retention, especially with hydrochlorothiazide, but it is secondary to direct blood pressure monitoring.
D. Monitoring the respiratory rate is generally less critical in this scenario unless there are specific concerns related to medication side effects or respiratory conditions.